Healthcare Provider Details

I. General information

NPI: 1164738399
Provider Name (Legal Business Name): KERRY SHAWN HARRIS CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 E LOHMAN AVE STE 320
LAS CRUCES NM
88011-8262
US

IV. Provider business mailing address

4351 E LOHMAN AVE STE 320
LAS CRUCES NM
88011-8262
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-0116
  • Fax: 575-522-0094
Mailing address:
  • Phone: 575-522-0116
  • Fax: 575-522-0094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberCNS-00220
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-54594
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: